By Joe Flower

A young man seeking wisdom traveled far in his search, and one day he came to a
Guru seated at the base of a mountain, and said, "I have been told by many and
sundry that you know the path up the Mountain of Wisdom. Is this true?"

"Yes, it is," said the Guru, who had a flowing white beard and long bushy white
eyebrows that curled up at the tips. He was wearing nothing of any consequence
save for some beads around his neck and a dhoti wrapped modestly about
his loins.

"Is this the mountain?" asked the Seeker.

"Yes it is," said the Guru. "There is only one mountain. I am the guardian of
the path."

"Can you take me up the path?"

The Guru's great curling eyebrows scrunched together in a furrow of doubt. He
was silent for a long time, gazing at the Seeker as if he could see deeply into
him. Finally he said,

"I can take you
up the path, but
can you follow?"

"I can take you up the path, but can you follow? The way
is long and arduous, the difficulties many, the temptations to turn aside are
legion. Many attempt the path, few succeed."

"I would like to try."

"You will have to serve as my chela, my disciple, and do whatever I ask,
no matter how difficult, until we get to the top."

"I promise," said the Seeker.

So they set off up the path, the Guru moving with amazing speed for so old a
man, the Seeker puffing to keep up. The path was, indeed, long. Hours became
days, days turned into weeks. The Seeker would have become lost many times
without the Guru. At various points the Guru stopped and made the Seeker
perform some task or learn some skill, often what seemed to the Seeker a
senseless one. The Guru would go no further until the Seeker had learned the
skill. Months went by. Further and further up the mountain they toiled, through
brambles and deep canyons, over rocks and through caves. They never met anyone
else on the path.

After some time (the Seeker had long lost track, but I will tell you that it
was, to be precise, one year, one day, four hours and seven minutes since they
had started), they reached the summit of the Mountain of Wisdom. It was broad
and flat and, to the Seeker's enormous surprise, crowded. The Guru seemed to
know who everyone was and, standing on a small prominence, he pointed them out
for the Seeker -- the milling crowds of Hindus, Jews, Muslims, Buddhist monks,
Catholic nuns and priests, as well as badminton players, rock stars,
stockbrokers, mothers with babies, grandmothers, a woman Prime Minister, four
astronomers and at least one rodeo clown. As they watched, what looked like a
tour bus drove up onto the mountain from the other side.

The Seeker sat down, speechless. Finally he looked at the Guru, struggling to
get out the words.

"But . . .
you said . . .
one path."

"But . . . you said . . . one path."

"No," said the Guru gently. "I said, `One mountain.' There are many paths."

"But . . . your way was so difficult. And we never met anyone."

"That was not my way. That was your way. Everyone has their own. That was the
easiest path you could have taken. The path to wisdom is always exactly hard
enough -- that is, it is excruciatingly difficult. You must trust me on this."

The
making of a physician

So -- how has your path been so far? What have you trained for? How does that
training fit with what you are doing now? Take a look at the path of today's physicians, and think about your own path.

Every physician goes through a long and grueling process of selection,
self-selection, and training. That training is built on a foundation of
learning, by rote, an enormous amount of information about the human body,
about diseases, symptoms and therapies, about tests and diagnostics. Add to
that base the skills of gathering more information, plus certain physical
skills such as finding a vein with a hypodermic, or entubating an air passage,
along with the mental skills that of coming rapidly to a logical judgment based
on that information -- and you have a basic medical education. The process
selects (and the trainees self-select) for people who find this process
congenial. The process is based on the powers of memory, observation, and
logic. Though doctors are trained to consult, it is at root an individual
process. And it is reactive -- the doctor responds to the presenting
situation.

And there is a meta-training as well, a set of assumptions, postures and
beliefs that is often unspoken, but is in its consequences as powerful as
anything a physician learns. In his rounds, the intern learns not only that he
must know everything, but also that he must appear to know everything. For the
patient to have confidence, the physician must seem an Olympian. The fledgling
physician

He learns to
hide his ignorance,
dissemble his fear,
elide his vulnerability.

learns to hide his ignorance, to dissemble his fear, to elide his
vulnerability.

Today, out on the floor, in the clinic, in the executive suite at the
healthcare center, things are changing. Medicine is changing, healthcare is
changing, even the patients are changing. Increasingly, you are being asked to
exercise skills that run against the grain of your training. Patients are
demanding more information and taking more responsibility. Some of them are
going on the Internet and researching their particular condition more deeply
than you would ever have the time to do. Managed care is pushing at the edges
of ethical practice, demanding that physicians operate in ways that may not be
in the best interests of the patient. At the same time, outcomes management and
other new ways of improving quality increasingly demand that physicians
collaborate with each other, with care managers, and with patients.

Medical knowledge is expanding faster than any physician can keep up -- and the
means to search for and process that information are improving almost as
rapidly. Genetic markers, polymerase chain reactors, and other early detection
techniques will increasingly allow physicians to get involved in the disease
process far earlier, often in a preventive rather than reactive mode, turning
some of the practice of medicine into a kind of individualized public health.
And as these techniques become widely available and their cost efficiencies
become obvious, care managers will increasingly insist that they be used.

So where the old medicine was reactive, the new medicine increasingly will be
preventive. Where the old medicine was based on memory, the new medicine
increasingly will be based on an expanded ability to gather information. Where
the old medicine was, at root, a matter of an individual physician's judgment, the new
medicine increasingly will be collaborative, based on care guidelines, on
teamwork, on consultation, on handing over some of the power of judgment,
logic, and information-searching to colleagues, to technological tools, and
even to the patient and the patient's family. Where the old medicine was
authoritative and hierarchical, the new medicine increasingly will be advisory.

The troubles of the hyphen

When a physician becomes a physician-executive, the shift is similar, but even
more abrupt, more confusing, less marked by signposts. To be an organizational
leader -- especially in the 1990s, in healthcare more than in any other
industry -- is to be a master of teamwork, a maven of process, at home with
ambiguity, comfortable with change, a nurturer of consensus, yet decisive,
ready to move in the face of all the ambiguity.

Suddenly the patient, the passive recipient of care, becomes the "customer"
and, as Gail Warden, CEO of Henry Ford in Detroit, puts it, "The customer is
the boss."

Suddenly decisiveness, a quality very familiar to a physician, has to blend
with collaboration. After 11 years as a healthcare CEO, Dr. James Reinertsen of
Health System Minnesota told me, "At first I was under the impression that
people looked to me to decide. Now I rarely come to a meeting thinking that it
is my job to decide. It's far more important for me to elicit the best
decisions from the group, and to see that a decision is made. Now I realize
that I do not always know the best course."

Pat Hays, former CEO of Sutter Helath in California and now CEO of Blue
Cross/Blue Shield, echoed Reintertsen almost exactly: "In the earlier part of
my career, I felt that I had to be the center of all answers. Now it is more a
matter of shaping the philosophy and the dialog, setting the basic strategic
directions, and then getting out of their way."

So did Stephanie S. McCutcheon, CEO of St. Louis Health Care Network:

"I was
raised
to see a leader
as the person with
all the answers."

"I was
raised to see a leader as the person with all the answers. When I was younger,
often I would go into a meeting with an answer ready to go. Now I walk into
meetings without answers and craft the answers at the meeting. My experience as
a leader is that it's my job to facilitate the development of the vision, to
get the team around the table to find the answers, to pose the proper
questions, to look creatively for solutions."

Facilitating the vision, eliciting the group decision, shaping the dialogue
and getting out of the way: these don't sound like skills taught in medical
school, or learned in clinical practice.

The physician is used to rapid, relatively clear feedback -- the patient gets
better or worse or dies. The executive is used to feedback from the
marketplace, the industry, her colleagues and her subordinates, that is subtle,
mercurial, and easy to misinterpret. Communicating a sense of vulnerability,
which could be a problem in a physician, is occasionally a necessity in a
leader. The ability to communicate a vision, rarely called for in a physician,
is a basic job skill for a leader. The Olympian aura of authority, knowledge,
and judgment that the physician has so carefully cultivated would be a stone
around the neck of the executive.

Finding
the new path

The hyphenated physician-executive lives in state of culture shock. If she does
not understand what this shock means, and where it comes from, she will forever
be questioning her fellow executives' motivations and competence. Every
transaction will seem odd, every meeting interminable, and most processes
unnecessary.

If she wants to stop feeling weird and start being more productive as a
hyphenate, she has to take two major steps.

The first major step is to recognize that the traits of the true organizational
leader are, in fact, skills. The skills of the leader who shows up at a meeting
without a pre-made decision, who "facilitates consensus," who helps the group
"look creatively for solutions" may seem so soft and fuzzy as to be invisible
to the medical mind. The physician may find himself saying,

""That's a
skill
set?
What's to
learn here?"

"That's a skill
set? What's to learn here?" The physician may find himself wondering how these
people manage to hold down a job at all, let alone become a major suit in the
front office, without any noticeable skills. This way of thinking does not make
for fruitful, efficient relationships.

But anyone who has actually run a major healthcare organization for a
significant period of time can attest that these skills are real, that they are
powerful, that you can't run a healthcare organization today without them.
These skills do not represent a better or worse way of thinking and acting.
Rather, they are the right skills for their context. They are a different path
up the Mountain of Wisdom.

The second major step is to learn these skills, to set out deliberately, this
far along in life, on a new kind of training, a new path. It will take time. As
these are significant skills, learning them is a non-trivial task. No one book
or seminar will give them to you, no single class or training course.
Executives I have interviewed consistently talk about many years, even decades,
of experience shaping their style.

"Oh, no." The Guru seemed shocked. "No one is allowed to stay here. Do you see
any houses up here? Oh, no no no no. If wisdom is what you seek, it is here, on
this mountain -- and you must ascend the mountain over and over again, by one
path and then by another. That is how we attain wisdom. That's how I became a
guru -- and that's why I scoot up the mountain so easily. Come along!"

And with that he hopped off the rock and vanished back the way they had come.